Fast Track Urgent Care

2019

Passionate about healthcare. Committed to your care.

Fast Track Urgent Care is dedicated to delivering quality healthcare

options to employees as well as patients. We understand the healthcare

for you and your loved ones are of top priority. That is precisely why we

offer a variety of benefit and plan options.

CONTENTS & CONTACT INFORMATION

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

HUMAN RESOURCES

Stephanie Lacy

slacy@fasttrackurgentcare.com

Phone

813-925-1903

Alexandra Chavez

achavez@fasttrackurgentcare.com

Phone

813-925-1903

BROKER PARTNER - M.E. WILSON COMPANY

Amanda Sands

Phone

813-349-2259

asands@mewilson.com

MEDICAL

Provider

FloridaBlue

Phone

1-800-583-9072

Web Address

www.bcbsfl.com

DENTAL

Provider

SunLife Financial

Phone

1-888-222-3660

Web Address

www.sunlifedentalbenefits.com

VISION

Provider

SunLife Financial

Phone

1-800-451-2513

Provider Web Address

www.sunlife.com

LIFE INSURANCE

Provider

SunLife Financial

Phone

1-800-451-2513

Provider Web Address

www.sunlife.com

SUPPLEMENTAL INSURANCE

Provider

SunLife Financial

Phone

1-800-451-2513

Provider Web Address

www.sunlife.com

BENEFIT INFORMATION

Benefit

Who pays the cost?

YOUR BENEFITS PLAN

Fast Track Urgent Care pays the majority of the cost for medical coverage for yourself. You have the option to enroll your covered dependents.

Medical

Fast Track Urgent Care offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.

Fast Track Urgent Care offers dental on on a voluntary basis for you and your covered dependents.

Dental

Fast Track Urgent Care offers vision on a voluntary basis for you and your covered dependents.

Vision

Fast Track Urgent Care pays 100% for your Basic Life insurance. You have the option to purchase additional life insurance for yourself and your dependents. Fast Track Urgent Care offers short term disability on a voluntary basis for you and your covered dependents.

Life and AD&D

Short Term Disability

Fast Track Urgent Care offers supplemental benefits on a voluntary basis for you and your covered dependents.

Supplemental Benefits

PRE-TAX BENEFITS

CHOOSING YOUR BENEFITS

The premiums for elected coverages are taken from your paycheck automatically. There are two ways that the money can be taken out, pre-tax or post-tax.

WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?

There is a definite advantage to paying for some benefits with before-tax money. Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.

WHICH BENEFIT PREMIUMS ARE TAKEN BEFORE TAX?

BEFORE tax – Medical, Dental, and Vision

AFTER tax – Life and Disability

ELIGIBILITY

All Regular full-time employees are eligible to join the Fast Track Urgent Care Benefits Plan on the first of the month following 60 days of employment. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week. You may also enroll your dependents in the Benefits Plan when you enroll.

WHO’S AN ELIGIBLE DEPENDENT?

• Your legal spouse

• Your married or unmarried natural children, step-children living with you, legally adopted child(ren) and any other child(ren) for whom you have legal guardianship, up to age 26 • A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible they must: • Be unmarried and not have a dependent of his or her own, AND • Be a resident of Florida or full-time student, AND • Not have coverage of their own, or covered under another plan, including Medicare

WHEN CAN YOU ENROLL?

You can sign up for Benefits at any of the following times:

• As a new hire, at your initial eligibility date.

• During Annual Open Enrollment.

• Within 30 days of a qualified family-status change.

If you do not enroll at one of the above times, you may enroll during the next annual open enrollment period.

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:

• Your marriage

• Change in your work status that affects your benefits

• Your divorce

• Change in residence that affects your eligibility for coverage

• Birth or adoption of an eligible child

• Change in your child’s eligibility for benefits

• Death of your spouse or covered child

• Receiving Qualified Medical Child Support Order (QMCSO)

• Change in your spouse’s work status that affects your benefits

You must notify and submit documentation to Human Resources within 30 days of a qualified life event . The IRS allows changes to be made within 60 days for those eligible for Medicaid or CHIP under HIPAA Special Enrollment Rights. If you fail to do so you will be required to wait

until the next annual enrollment period to make benefit changes unless you have another family status change.

WHEN COVERAGE ENDS

Coverage will stop on the last day of the month in which employment with the company ends. Life and Disability will end on your last date of employment.

MEDICAL INFORMATION

Fast Track Urgent Care offers medical coverage through FloridaBlue, you have three plan options to choose from. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “BlueCare HMO” network. The chart below provides a brief overview of the medical plan offered.

BUY-UP PLAN #1 BlueCare 54

BUY-UP PLAN #2 BlueCare 48

BASE PLAN BlueCare 128/129

IN-NETWORK DEDUCTIBLE

(your first dollar cost for covered in-network claims)

Deductible (Individual / Family)

$2,500 / $5,000

$5,000 / $10,000

$2,000 / $6,000

COINSURANCE (your responsibility on claims costs once you’ve met the deductible) 20% 30% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) Maximum Out-of-Pocket (Individual / Family) $5,000 / $10,000 $6,350 / $12,700

20%

$5,500 / $11,000

Maximum Includes

Deductible, Coinsurance, Prescription Costs & Copays

PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.

Covered 100%, no cost to you

OFFICE VISITS

Referral Required

No (PCP Required)

Office Visits (Illness/Injury)

Deductible & Coinsurance

$40 Copay

$35 Copay

Specialist Visits

Deductible & Coinsurance

$65 Copay

HOSPITAL SERVICES

$100 POD 1 + Deductible & Coinsurance

Inpatient Hospital

Deductible & Coinsurance Deductible & Coinsurance

Outpatient Surgery

Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance

Emergency Room

Deductible & Coinsurance

$300 Copay

Urgent Care

Deductible & Coinsurance

$85 Copay

$70 Copay

2 Free visits per calendar year & Flu Shot

FAST TRACK URGENT CARE

DIAGNOSTIC TESTING Lab – Freestanding facility

Deductible & Coinsurance

Covered 100%

Advanced Imaging (MRI, CAT, PET, etc.)

Deductible & Coinsurance

$300 Copay

(once deductible has been met)

PRESCRIPTIONS

Retail (30 day supply) Tier 1 / 2 / 3

$10 / $50 / $80

OUT-OF-NETWORK 1

Refer to plan summary for details Semi Monthly Cost for Coverage

Employee Only

$81.72

$124.23

$150.53

Employee + Spouse

$372.14

$440.75

$540.07

Employee + Child(ren)

$257.81

$313.15

$387.64

Employee + Family

$528.81

$615.60

$748.96

1 Per Occurrence Deductible This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. 3

HEALTH SAVINGS ACCOUNT

Employees enrolling in the Base Medical Plan are eligible to open and contribute to a Health Savings Account (H.S.A). With an H.S.A you have the ability to put money side, through payroll deductions, to help pay for H.S.A eligible expenses.

IRS Annual Maximum HSA Contribution Limits

2019

Employee Only

$3,500

Family

$7,000

Additional $1,000 annually catch-up amounts for available for employees 55 years or older

WHAT ARE THE BENEFITS OF A HSA?

• The money you put aside is PRE-TAX • The H.S.A is a bank account in your name. If you retire or should you leave Fast Track Urgent Care you take this account with you. • The account rolls over year to year. You will not have to forfeit any unused funds. • You will receive a debit card upon opening an H.S.A for quick and easy utilization of the funds. • The list of eligible expenses is vast! These expenses include things covered under the medical, dental, and vision coverage – as well as some items that aren't! Below is a brief list of eligible expenses.

• Acupuncture and Chiropractic services • Alcohol and drug dependency treatment • Ambulance • Artificial limbs • Contact lenses and solution • Dental expenses • Prescription Drugs and Over the Counter Drugs (when ordered by a doctor) • Eye surgery (laser eye surgery or radial keratotomy)

• Fertility enhancements • Hearing aids and batteries for use • Long-term care and Nursing home

• Maternity Expenses • Organ transplants • Physical and speech therapies • Smoking-cessation programs and products

• Vasectomy • Wheelchairs

DENTAL INSURANCE

Fast Track Urgent Care offers dental coverage through SunLife Financial, which is a Dental PPO Plan. This plans allow you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible for paying the difference between SunLife’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

PPO DENTAL PLAN

In-Network

Calendar Year Deductible

Individual

$50

Family

$150

Annual Maximum (pre covered member)

Per covered member

$1,000

Preventive Services Exams (2 in 12 months), Cleanings, & Fluoride

Covered in full

Basic Services

Fillings, Simple Extractions, Perio, Endo, & Periodontal Maintenance

Covered 90% after deductible

Major Services

Crowns, Bridges, Surgical Extractions, Root Canal, & Dentures

Covered 60% after deductible

Orthodontia (Child only through age 18)

50% up to $1,500 (Lifetime Max)

Out-of Network 1

Calendar Year Deductible

$50 / $150

Schedule of Services: Preventive

Covered 80% Covered 50% after deductible Covered 30% after deductible

Basic Major

Orthodontia

None

Annual Maximum (pre covered member)

$ 1,000

90 th Usual & Customary Charges

Basis of Payment

Semi Monthly Cost for Coverage

Employee Only

$13.82

Employee + Spouse

$27.29

Employee + Child(ren)

$44.05

Employee + Family

$57.52

1 Subject to balance billing. Please refer to your plan document for specific details.

VISION INSURANCE

Fast Track Urgent Care offers vision coverage through SunLife Financial. The SunLife vision plan allows you the flexibility to see any provider. To search in-network providers visit www.sunlife.com. You pay expenses at the time of service and file a claim for reimbursement. Below is a list of the reimbursement schedule.

VISION PLAN

In-Network Routine Eye Exams

Every 12 months $10 Copay

Lenses 2

Every 12 months

Single Vision Bifocal Trifocal Lenticular

$10 Copay

Frames

Every 24 months

$130 allowance PLUS 20% off cost over the allowance

Contact Lenses (in lieu of glasses)

Every 12 months

Elective Contact Lenses

$130 allowance

Medically Necessary

$10 Copay

Out-of-Network 1 Routine Eye Exams

Every 12 months Reimbursed up to $52 Every 12 months Reimbursed up to $55 Reimbursed up to $75 Reimbursed up to $95 Reimbursed up to $125 Every 24 months Reimbursed up to $57 Every 12 months Reimbursed up to $210 Reimbursed up to $210

Lenses 2

Single Bifocal Trifocal Lenticular

Frames

Contact Lenses (in lieu of glasses) Elective Medically necessary

Semi Monthly Cost for Coverage

Employee Only

$3.23

Employee + Spouse

$6.45

Employee + Child(ren)

$7.09

Employee + Family

$10.32

1 You pay expenses at the time of service and file a claim for reimbursement

2 Lenses benefit listed are for a pair of lenses.

LIFE AND AD&D INSURANCE

BASIC LIFE INSURANCE AND AD&D

Fast Track Urgent Care provides all benefits eligible employees Basic Term Life Insurance and AD&D at no cost to you ! This benefit is $25,000 Life and $25,000 AD&D. This coverage is through SunLife Financial.

VOLUNTARY LIFE INSURANCE AND AD&D

Fast Track Urgent Care offers employees the option to purchase additional life insurance for yourself. If you purchase additional life insurance for yourself you are also able to purchase life insurance for your spouse and/or your dependent child(ren). This coverage is though SunLife Financial.

HOW MUCH LIFE INSURANCE CAN I PURCHASE?

You may purchase life insurance for yourself in $10,000 increments, for as little as $10,000 and as much as $500,000.

You may purchase life insurance for your spouse in $5,000 increments, for as little as $5,000 and as much as $250,000 (not to exceed 50% of your voluntary life insurance benefit).

You may purchase life insurance for your child(ren) in $1,000 increments, for as little as $2,000 and as much as $10,000 (not to exceed 50% of your voluntary life insurance benefit). The cost to cover multiple children is the same as the cost to cover one, if you cover one child you must cover all eligible children.

WHAT’S GUARANTEE ISSUE?

Guarantee Issue (GI) is the amount you can purchase as a newly eligible employee and at this year’s open enrollment without having to provide evidence of good heath (Evidence of Insurability (EOI)).

The GI for yourself is $100,000. The GI for your spouse is $50,000 (not to exceed 50% of your voluntary life insurance benefit). The GI for your child(ren) is $10,000 (not to exceed 50% of your voluntary life insurance benefit).

WHEN WOULD I NEED TO SHOW EVIDENCE OF GOOD HEALTH TO GET LIFE INSURANCE?

If you elect a benefit over GI as a new hire, a benefit outside of your newly eligible period, or an increase to your current benefit you will be required to provide Evidence of Insurability (EOI). Completed EOIs should be submitted to SunLife Financial directly.

SUPPLEMENTAL PROGRAMS

SHORT TERM DISABILITY

Helps you pay everyday living expenses and out-of-pocket expenses not covered by major medical plans. Provides monthly benefits to replace a portion of your income if you’re unable to work due to a covered disability (off-job accident, illness or pregnancy).

ACCIDENT

True 24 hour protection for both on and off-the-job injuries. Provides cash for medical expenses (even if covered by medical insurance), income for lost wages, hospital stays, dislocations and fracture benefit, and accidental death and dismemberment.

Pays directly to you over-and-above any other coverage in-force.

Benefit is portable, (you can take it with you) with no change in price even if you change jobs.

CRITICAL ILLNESS

Provides lump sum upon diagnosis of a covered critical illness for you to use where it’s needed most. You can select from a $10,000 or $20,000 benefits. This benefit amount can help with deductibles, coinsurance, caregivers, special medical equipment, loss of income or extra living expenses.

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

Required Annual Employee Disclosure Notices

THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996 The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. Further, a health insurer or health maintenance organization may not: 1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to avoid providing such length of stay coverage; 2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage; 3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay coverage; 5. Restrict benefits for any portion of a period within a hospital length of stay described in this notice. These benefits are subject to the plan’s regular deductible and co- pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Effective January 1, 2009 group health plans are required by Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s new Medicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this information on your benefits enrollment form when enrolling into benefits. 4. Require a mother to give birth in a hospital; or SECTION 111

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires Fast Track Urgent Care to notify you, as a participant or beneficiary of the Fast Track Urgent Care Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010 If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post- secondary educational institution (includes colleges, universities, some trade schools and certain other post- secondary institutions). Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary. 1. All stages of reconstruction of the breast on which the mastectomy was performed; MICHELLE’S LAW

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

Required Annual Employee Disclosure Notices continued

HIPAA PRIVACY POLICY FOR FULLY- INSURED PLANS WITH NO ACCESS TO PHI

PATIENT PROTECTION:

If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, or for information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your application may invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation. CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009 Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after you or your dependent is determined to be eligible for State premium assistance. Please note that premium assistance is not available in all states.

I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-enrollment information. Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. §160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis-enrollment information. The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. §164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy requirements.

II. Insurer for group health plan will provide privacy notice

The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor.

III. No intimidating or retaliatory acts

The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA.

IV. No Waiver

The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan.

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

MEDICARE PART D

This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with FloridaBlue and about your options under Medicare’s prescription drug Plan. If you are considering joining, you should compare your current coverage including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. UnitedHealthcare has determined that the prescription drug coverage offered by the Welfare Plan for Employees of Fast Track Urgent Care under the UnitedHealthcare option are, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. You should also know that if you drop or lose your coverage with FloridaBlue and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. _________________________________________________ You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current FloridaBlue coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current FloridaBlue coverage, be aware that you and your dependents will be able to get this coverage back. When can you join a Medicare Drug Plan?

When will you pay a higher premium (penalty) to join a Medicare drug Plan? You should also know that if you drop or lose your current coverage with FloridaBlue and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For more information about this notice or your current prescription drug coverage… Contact our office for further information (see contact information below). NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through FloridaBlue changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1- 800-325-0778). Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. • Visit www.medicare.gov

Date: 1/1/19 Name of Entity/Sender: Fast Track Urgent Care Contact--Position/Office: Human Resources 3301 W Gandy Blvd. Tampa, FL 33611 Phone Number: 813-925-1903

GENERAL NOTICE OF COBRA RIGHTS

*Continuation coverage rights under COBRA*

INTRODUCTION

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to the employer sponsoring the Plan. WHEN IS COBRA CONTINUATION COVERAGE AVAILABLE?

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries may elect COBRA continuation coverage, but they may be required to pay for the coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. WHAT IS COBRA CONTINUATION COVERAGE?

GENERAL NOTICE OF COBRA RIGHTS

*Continuation coverage rights under COBRA*

HOW

COBRA

CONTINUATION

COVERAGE PROVIDED?

ARE THERE OTHER COVERAGE OPTIONS BESIDES COBRA CONTINUATION COVERAGE? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. IF YOU HAVE QUESTIONS

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. DISABILITY EXTENSION OF 18-MONTH PERIOD OF COBRA CONTINUATION COVERAGE: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 5-31-2020)

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact:

Human Resources

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer Name

4. Employer Identification Number (EIN)

Fast Track Urgent Care

65-1239194

5. Employer Address

6. Employer Phone Number

3301 W Gandy Blvd

7. City

8. State

9. Zip Code

Tampa

33611

10. Who can we contact about employee health coverage at this job?

Human Resources

11. Phone Number (if different from above)

12. E-mail address

813-925-1903

slacy@fasttrackurgentcare.com

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs

Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to:

All Employees. Eligible employees are:

All Full Time Employees working at least 30 hours.

Some employees. Eligible employees are:

With respect to dependents:

•

We do offer coverage. Eligible Dependents are:

Your Legal Spouse or qualified domestic partner. Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are under 26 years of age. A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits if the dependent is: • unmarried and not have dependents of his or her own; AND • Be a resident of Florida or a student; AND • Not have coverage of their own, or covered under any other plan; AND • Not entitled to benefits under Medicare

We do not offer coverage.

X If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

**Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee)

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15)

No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan?

$ 81.72

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16. What change will the employer make for the new plan year?

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15)

a. How much would the employee have to pay in premiums for this plan?

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NOTES

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